[xls] · web viewthis is a non-covered service because it is a routine/preventive exam or a...

Prepaid Denied Claims- Dental Summary Dental Benefit Plan ReportingHealth Plan ID: Document ID: PI173Health Plan Name: Document Name: Prepaid Denied ClaimsHealth Plan Contact: Reporting Frequency: monthlyContact Email: Report Due Date: 15th of the month following end of reporting periodReport Period Start Date: File Type: ExcelReport Period End Date: Subject Matter: Informatics (I)

CARC CARC Description Total Count of CARCs

Total

*Institutional claims counted a header level and professional/outpatient claims counted at claim line level.

Submission Date of Report:

Prepaid Denied Claims- Dental Summary Dental Benefit Plan ReportingHealth Plan ID: Document ID: PI173Health Plan Name: Document Name: Prepaid Denied ClaimsHealth Plan Contact: Reporting Frequency: monthlyContact Email: Report Due Date: 15th of the month following end of reporting periodReport Period Start Date: File Type: ExcelReport Period End Date: Subject Matter: Informatics (I)

Medicaid ID Billing Provider NPI Plan ICN Claim Type CDT CARC Code 1 CARC Code 2 CARC Code 3 CARC Code 4 CARC Code 5 RARC Code 1 RARC Code 2 RARC Code 3

Submission Date of Report:

Servicing Provider NPI

Billing Provider Type

Billing Provider Taxonomy

Servicing Provider Type

Servicing Provider Taxonomy

ER = 0Non-ER = 1

Date of Service

Provider Billed Amount

Date Received

Date Denied

Primary Diagnosis

Revenue Code

PA Approved (Y/N)

Prepaid Denied Claims- Claim Adjustment Reason Code (CARC) Dictionary

CARC Description1 Deductible Amount

Start: 01/01/19952 Coinsurance Amount

Start: 01/01/19953 Co-payment Amount

Start: 01/01/19954

Start: 01/01/1995 | Last Modified: 09/20/20095








Start: 01/01/1995 | Last Modified: 09/20/200913 The date of death precedes the date of service.

Start: 01/01/199514 The date of birth follows the date of service.

Start: 01/01/199515

The authorization number is missing, invalid, or does not apply to the billed services or provider.



Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/200918

Start: 01/01/1995 | Last Modified: 06/02/201319 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

Start: 01/01/1995 | Last Modified: 09/30/200720 This injury/illness is covered by the liability carrier.

Start: 01/01/1995 | Last Modified: 09/30/200721 This injury/illness is the liability of the no-fault carrier.


This care may be covered by another payer per coordination of benefits.


Start: 01/01/1995 | Last Modified: 09/30/201224 Charges are covered under a capitation agreement/managed care plan.

Start: 01/01/1995 | Last Modified: 09/30/200725 Payment denied. Your Stop loss deductible has not been met.

Start: 01/01/1995 | Stop: 04/01/2008

Claims Adjustment Reason Code (CARC)

The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

26 Expenses incurred prior to coverage.Start: 01/01/1995

27 Expenses incurred after coverage terminated.Start: 01/01/1995

28 Coverage not in effect at the time the service was provided.Start: 01/01/1995 | Stop: 10/16/2003Notes: Redundant to codes 26&27.

29 The time limit for filing has expired.Start: 01/01/1995

30

Start: 01/01/1995 | Stop: 02/01/200631 Patient cannot be identified as our insured.

Start: 01/01/1995 | Last Modified: 09/30/200732 Our records indicate that this dependent is not an eligible dependent as defined.

Start: 01/01/199533 Insured has no dependent coverage.

Start: 01/01/1995 | Last Modified: 09/30/200734 Insured has no coverage for newborns.

Start: 01/01/1995 | Last Modified: 09/30/200735 Lifetime benefit maximum has been reached.

Start: 01/01/1995 | Last Modified: 10/31/200236 Balance does not exceed co-payment amount.

Start: 01/01/1995 | Stop: 10/16/200337 Balance does not exceed deductible.

Start: 01/01/1995 | Stop: 10/16/200338 Services not provided or authorized by designated (network/primary care) providers.

Start: 01/01/1995 | Last Modified: 06/02/2013 | Stop: 01/01/2013Notes: CARC codes 242 and 243 are replacements for this deactivated code

39Services denied at the time authorization/pre-certification was requested.

Start: 01/01/199540

Start: 01/01/1995 | Last Modified: 09/20/200941 Discount agreed to in Preferred Provider contract.

Start: 01/01/1995 | Stop: 10/16/200342 Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)

Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/200743 Gramm-Rudman reduction.

Start: 01/01/1995 | Stop: 07/01/200644 Prompt-pay discount.

Start: 01/01/199545

Start: 01/01/1995 | Last Modified: 11/01/201546 This (these) service(s) is (are) not covered.

Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 96.

47This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

Start: 01/01/1995 | Stop: 02/01/200648 This (these) procedure(s) is (are) not covered.


49




Start: 01/01/1995 | Stop: 02/01/200653 Services by an immediate relative or a member of the same household are not covered.

Start: 01/01/199554


Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.

Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)

This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.

Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

55



Start: 01/01/1995 | Stop: 06/30/2007Notes: Split into codes 150, 151, 152, 153 and 154.

58





62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007

63 Correction to a prior claim.Start: 01/01/1995 | Stop: 10/16/2003

64 Denial reversed per Medical Review.Start: 01/01/1995 | Stop: 10/16/2003

65 Procedure code was incorrect. This payment reflects the correct code.Start: 01/01/1995 | Stop: 10/16/2003

66 Blood Deductible.Start: 01/01/1995

67 Lifetime reserve days. (Handled in QTY, QTY01=LA)Start: 01/01/1995 | Stop: 10/16/2003

68 DRG weight. (Handled in CLP12)Start: 01/01/1995 | Stop: 10/16/2003

69 Day outlier amount.Start: 01/01/1995

70 Cost outlier - Adjustment to compensate for additional costs.Start: 01/01/1995 | Last Modified: 06/30/2001

71 Primary Payer amount.Start: 01/01/1995 | Stop: 06/30/2000Notes: Use code 23.

72 Coinsurance day. (Handled in QTY, QTY01=CD)Start: 01/01/1995 | Stop: 10/16/2003

73 Administrative days.Start: 01/01/1995 | Stop: 10/16/2003

74 Indirect Medical Education Adjustment.Start: 01/01/1995

75 Direct Medical Education Adjustment.Start: 01/01/1995

76 Disproportionate Share Adjustment.Start: 01/01/1995

77 Covered days. (Handled in QTY, QTY01=CA)Start: 01/01/1995 | Stop: 10/16/2003

78 Non-Covered days/Room charge adjustment.Start: 01/01/1995

79 Cost Report days. (Handled in MIA15)Start: 01/01/1995 | Stop: 10/16/2003

80 Outlier days. (Handled in QTY, QTY01=OU)Start: 01/01/1995 | Stop: 10/16/2003

81 Discharges.Start: 01/01/1995 | Stop: 10/16/2003

82 PIP days.Start: 01/01/1995 | Stop: 10/16/2003

83 Total visits.Start: 01/01/1995 | Stop: 10/16/2003

84 Capital Adjustment. (Handled in MIA)Start: 01/01/1995 | Stop: 10/16/2003

85 Patient Interest Adjustment (Use Only Group code PR)Start: 01/01/1995 | Last Modified: 07/09/2007Notes: Only use when the payment of interest is the responsibility of the patient.

86 Statutory Adjustment.

Procedure/treatment/drug is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective 1/1/2017: Adjusted for failure to obtain second surgical opinion

Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.

86

Start: 01/01/1995 | Stop: 10/16/2003Notes: Duplicative of code 45.

87 Transfer amount.Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012

88 Adjustment amount represents collection against receivable created in prior overpayment.Start: 01/01/1995 | Stop: 06/30/2007

89 Professional fees removed from charges.Start: 01/01/1995

90Ingredient cost adjustment. Note: To be used for pharmaceuticals only.

Start: 01/01/1995 | Last Modified: 07/01/200991 Dispensing fee adjustment.

Start: 01/01/199592 Claim Paid in full.

Start: 01/01/1995 | Stop: 10/16/200393 No Claim level Adjustments.

Start: 01/01/1995 | Stop: 10/16/2003Notes: As of 004010, CAS at the claim level is optional.

94 Processed in Excess of charges.Start: 01/01/1995

95 Plan procedures not followed.Start: 01/01/1995 | Last Modified: 09/30/2007

96


Start: 01/01/1995 | Last Modified: 09/20/200998 The hospital must file the Medicare claim for this inpatient non-physician service.

Start: 01/01/1995 | Stop: 10/16/200399 Medicare Secondary Payer Adjustment Amount.

Start: 01/01/1995 | Stop: 10/16/2003100 Payment made to patient/insured/responsible party/employer.

Start: 01/01/1995 | Last Modified: 01/27/2008101 Predetermination: anticipated payment upon completion of services or claim adjudication.

Start: 01/01/1995 | Last Modified: 02/28/1999102 Major Medical Adjustment.

Start: 01/01/1995103 Provider promotional discount (e.g., Senior citizen discount).

Start: 01/01/1995 | Last Modified: 06/30/2001104 Managed care withholding.

Start: 01/01/1995105 Tax withholding.

Start: 01/01/1995106 Patient payment option/election not in effect.

Start: 01/01/1995107



Start: 01/01/1995 | Last Modified: 01/29/2012110 Billing date predates service date.

Start: 01/01/1995111 Not covered unless the provider accepts assignment.

Start: 01/01/1995112

Service not furnished directly to the patient and/or not documented.


Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007Notes: Use Codes 157, 158 or 159.

114Procedure/product not approved by the Food and Drug Administration.

Start: 01/01/1995115 Procedure postponed, canceled, or delayed.

Start: 01/01/1995 | Last Modified: 09/30/2007116 The advance indemnification notice signed by the patient did not comply with requirements.

Start: 01/01/1995 | Last Modified: 09/30/2007117 Transportation is only covered to the closest facility that can provide the necessary care.


Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

Payment denied because service/procedure was provided outside the United States or as a result of war.

118 ESRD network support adjustment.Start: 01/01/1995 | Last Modified: 09/30/2007

119Benefit maximum for this time period or occurrence has been reached.

Start: 01/01/1995 | Last Modified: 02/29/2004120 Patient is covered by a managed care plan.


121 Indemnification adjustment - compensation for outstanding member responsibility.Start: 01/01/1995 | Last Modified: 09/30/2007

122 Psychiatric reduction.Start: 01/01/1995

123 Payer refund due to overpayment.Start: 01/01/1995 | Stop: 06/30/2007

Notes: Refer to implementation guide for proper handling of reversals.

124 Payer refund amount - not our patient.Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007

Notes: Refer to implementation guide for proper handling of reversals.125

Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013126 Deductible -- Major Medical

Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008Notes: Use Group Code PR and code 1.

127 Coinsurance -- Major MedicalStart: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008Notes: Use Group Code PR and code 2.

128 Newborn's services are covered in the mother's Allowance.Start: 02/28/1997

129

Start: 02/28/1997 | Last Modified: 01/30/2011130 Claim submission fee.

Start: 02/28/1997 | Last Modified: 06/30/2001131 Claim specific negotiated discount.

Start: 02/28/1997132 Prearranged demonstration project adjustment.

Start: 02/28/1997133

Start: 07/01/2014 | Last Modified: 03/01/2015134 Technical fees removed from charges.

Start: 10/31/1998135 Interim bills cannot be processed.

Start: 10/31/1998 | Last Modified: 09/30/2007136 Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

Start: 10/31/1998 | Last Modified: 07/01/2013137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

Start: 02/28/1999 | Last Modified: 09/30/2007138 Appeal procedures not followed or time limits not met.

Start: 06/30/1999 | Last Modified: 09/30/2007139 Contracted funding agreement - Subscriber is employed by the provider of services.

Start: 06/30/1999140

Patient/Insured health identification number and name do not match.

Start: 06/30/1999141 Claim spans eligible and ineligible periods of coverage.

Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012142 Monthly Medicaid patient liability amount.

Start: 06/30/2000 | Last Modified: 09/30/2007143 Portion of payment deferred.

Start: 02/28/2001144 Incentive adjustment, e.g. preferred product/service.

Start: 06/30/2001145 Premium payment withholding

Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008Notes: Use Group Code CO and code 45.

146 Diagnosis was invalid for the date(s) of service reported.Start: 06/30/2002 | Last Modified: 09/30/2007

147 Provider contracted/negotiated rate expired or not on file.Start: 06/30/2002

148

Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

The disposition of this service line is pending further review. (Use only with Group Code OA). Note: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).

Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

148

Start: 06/30/2002 | Last Modified: 09/20/2009149 Lifetime benefit maximum has been reached for this service/benefit category.

Start: 10/31/2002150 Payer deems the information submitted does not support this level of service.




Payer deems the information submitted does not support this dosage.

Start: 10/31/2002 | Last Modified: 09/30/2007154 Payer deems the information submitted does not support this day's supply.

Start: 10/31/2002 | Last Modified: 09/30/2007155 Patient refused the service/procedure.

Start: 06/30/2003 | Last Modified: 09/30/2007156 Flexible spending account payments. Note: Use code 187.

Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009157 Service/procedure was provided as a result of an act of war.

Start: 09/30/2003 | Last Modified: 09/30/2007158 Service/procedure was provided outside of the United States.

Start: 09/30/2003 | Last Modified: 09/30/2007159 Service/procedure was provided as a result of terrorism.


Injury/illness was the result of an activity that is a benefit exclusion.

Start: 09/30/2003 | Last Modified: 09/30/2007161 Provider performance bonus

Start: 02/29/2004162

Start: 02/29/2004 | Stop: 07/01/2014Notes: Use code P1

163 Attachment/other documentation referenced on the claim was not received.Start: 06/30/2004 | Last Modified: 06/02/2013

164 Attachment/other documentation referenced on the claim was not received in a timely fashion.Start: 06/30/2004 | Last Modified: 06/02/2013

165 Referral absent or exceeded.Start: 10/31/2004 | Last Modified: 09/30/2007

166

Start: 02/28/2005167


Start: 06/30/2005 | Last Modified: 09/30/2007169 Alternate benefit has been provided.




Start: 06/30/2005 | Last Modified: 09/20/2009173 Service/equipment was not prescribed by a physician.

Start: 06/30/2005 | Last Modified: 07/01/2013174 Service was not prescribed prior to delivery.

Start: 06/30/2005 | Last Modified: 09/30/2007175 Prescription is incomplete.

Start: 06/30/2005 | Last Modified: 09/30/2007176 Prescription is not current.

Start: 06/30/2005 | Last Modified: 09/30/2007177 Patient has not met the required eligibility requirements.

Start: 06/30/2005 | Last Modified: 09/30/2007178 Patient has not met the required spend down requirements.



Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.

These services were submitted after this payers responsibility for processing claims under this plan ended.

This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.

Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

180 Patient has not met the required residency requirements.Start: 06/30/2005 | Last Modified: 09/30/2007

181 Procedure code was invalid on the date of service.Start: 06/30/2005 | Last Modified: 09/30/2007

182 Procedure modifier was invalid on the date of service.Start: 06/30/2005 | Last Modified: 09/30/2007

183



Start: 06/30/2005 | Last Modified: 09/20/2009186 Level of care change adjustment.


Start: 06/30/2005 | Last Modified: 01/25/2009188 This product/procedure is only covered when used according to FDA recommendations.

Start: 06/30/2005189

Start: 06/30/2005190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

Start: 10/31/2005191

Start: 10/31/2005 | Last Modified: 10/17/2010 | Stop: 07/01/2014Notes: Use code P2

192



Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.


Refund issued to an erroneous priority payer for this claim/service.

Start: 02/28/2006 | Last Modified: 09/30/2007196 Claim/service denied based on prior payer's coverage determination.


197 Precertification/authorization/notification absent.Start: 10/31/2006 | Last Modified: 09/30/2007

198 Precertification/authorization exceeded.Start: 10/31/2006 | Last Modified: 09/30/2007

199 Revenue code and Procedure code do not match.Start: 10/31/2006

200 Expenses incurred during lapse in coverageStart: 10/31/2006

201

Start: 10/31/2006 | Last Modified: 09/28/2014Notes: Not for use by Workers' Compensation payers; use code P3 instead.

202 Non-covered personal comfort or convenience services.Start: 02/28/2007 | Last Modified: 09/30/2007

203 Discontinued or reduced service.Start: 02/28/2007 | Last Modified: 09/30/2007

204 This service/equipment/drug is not covered under the patient’s current benefit planStart: 02/28/2007

205 Pharmacy discount card processing feeStart: 07/09/2007

206 National Provider Identifier - missing.Start: 07/09/2007 | Last Modified: 09/30/2007

207 National Provider identifier - Invalid format

The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)

Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.

Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.

Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

207

Start: 07/09/2007 | Last Modified: 06/01/2008208 National Provider Identifier - Not matched.


Start: 07/09/2007 | Last Modified: 07/01/2013210 Payment adjusted because pre-certification/authorization not received in a timely fashion

Start: 07/09/2007211

National Drug Codes (NDC) not eligible for rebate, are not covered.

Start: 07/09/2007212 Administrative surcharges are not covered

Start: 11/05/2007213 Non-compliance with the physician self referral prohibition legislation or payer policy.

Start: 01/27/2008214


215 Based on subrogation of a third party settlementStart: 01/27/2008

216 Based on the findings of a review organizationStart: 01/27/2008

217


218


219



221


222


Start: 06/01/2008224

Start: 06/01/2008225

Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)

Start: 06/01/2008226


Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only

Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)

Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only

Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).

The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)

Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)

Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.

Patient identification compromised by identity theft. Identity verification required for processing this and future claims.

Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

227


Start: 09/21/2008229



231


Start: 11/01/2009233

Start: 01/24/2010234

Start: 01/24/2010235 Sales Tax

Start: 06/06/2010236


Start: 06/05/2011238

Start: 03/01/2012 | Last Modified: 07/01/2013239 Claim spans eligible and ineligible periods of coverage. Rebill separate claims.


Start: 06/03/2012241 Low Income Subsidy (LIS) Co-payment Amount

Start: 06/03/2012242 Services not provided by network/primary care providers.

Start: 06/03/2012 | Last Modified: 06/02/2013Notes: This code replaces deactivated code 38

243 Services not authorized by network/primary care providers.Start: 06/03/2012 | Last Modified: 06/02/2013Notes: This code replaces deactivated code 38

244


245 Provider performance program withhold.Start: 09/30/2012

246 This non-payable code is for required reporting only.Start: 09/30/2012

247

Start: 09/30/2012

248

Start: 09/30/2012

249 This claim has been identified as a readmission. (Use only with Group Code CO)Start: 09/30/2012

Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication

Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)

No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.

Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.

Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.

This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)

The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.

Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).

250



Start: 09/30/2012 | Last Modified: 06/02/2013253 Sequestration - reduction in federal payment


Start: 06/02/2013255


256 Service not payable per managed care contract.#VALUE!

257

Start: 11/01/2013 | Last Modified: 06/01/2014Notes: To be used after the first month of the grace period.

258

Start: 11/01/2013259 Additional payment for Dental/Vision service utilization.

Start: 01/26/2014260 Processed under Medicaid ACA Enhanced Fee Schedule

Start: 01/26/2014261 The procedure or service is inconsistent with the patient's history.

Start: 06/01/2014262

Adjustment for delivery cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014263

Adjustment for shipping cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014264 Adjustment for postage cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014265 Adjustment for administrative cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014266 Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014267

Start: 11/01/2014 | Last Modified: 04/01/2015268 The Claim spans two calendar years. Please resubmit one claim per calendar year.

Start: 11/01/2014269

Start: 03/01/2015270

Start: 07/01/2015271

Start: 11/01/2015272 Coverage/program guidelines were not met.

Start: 11/01/2015273 Coverage/program guidelines were exceeded.

Start: 11/01/2015274 Fee/Service not payable per patient Care Coordination arrangement.

Start: 11/01/2015275

Start: 11/01/2015276

Services denied by the prior payer(s) are not covered by this payer.

The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).

The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).

An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).

Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.

The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)

Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.

Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Anesthesia not covered for this service/procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration.

Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with group code OA)

Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)

276

Start: 11/01/2015277

Start: 11/01/2015Notes: To be used during 31 day SHOP grace period.

278

Start: 07/01/2016A0 Patient refund amount.

Start: 01/01/1995A1

Start: 01/01/1995 | Last Modified: 09/20/2009A2 Contractual adjustment.

Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.

A3 Medicare Secondary Payer liability met.Start: 01/01/1995 | Stop: 10/16/2003

A4 Medicare Claim PPS Capital Day Outlier Amount.Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008

A5 Medicare Claim PPS Capital Cost Outlier Amount.Start: 01/01/1995

A6 Prior hospitalization or 30 day transfer requirement not met.Start: 01/01/1995

A7 Presumptive Payment AdjustmentStart: 01/01/1995 | Stop: 07/01/2015

A8 Ungroupable DRG.Start: 01/01/1995 | Last Modified: 09/30/2007

B1 Non-covered visits.Start: 01/01/1995

B2 Covered visits.Start: 01/01/1995 | Stop: 10/16/2003

B3 Covered charges.Start: 01/01/1995 | Stop: 10/16/2003

B4 Late filing penalty.Start: 01/01/1995

B5 Coverage/program guidelines were not met or were exceeded.Start: 01/01/1995 | Last Modified: 11/01/2015 | Stop: 05/01/2016Notes: This code has been replaced by 272 and 273.

B6

Start: 01/01/1995 | Stop: 02/01/2006B7

Start: 01/01/1995 | Last Modified: 09/20/2009B8

Start: 01/01/1995 | Last Modified: 09/20/2009B9 Patient is enrolled in a Hospice.


Start: 01/01/1995B11

Start: 01/01/1995B12 Services not documented in patients' medical records.

Start: 01/01/1995B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

Start: 01/01/1995B14 Only one visit or consultation per physician per day is covered.


Start: 01/01/1995 | Last Modified: 09/20/2009B16 'New Patient' qualifications were not met.


Start: 01/01/1995 | Stop: 02/01/2006B18

This procedure code and modifier were invalid on the date of service.

Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)

Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.

This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.

The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.

B19Claim/service adjusted because of the finding of a Review Organization.

Start: 01/01/1995 | Stop: 10/16/2003B20 Procedure/service was partially or fully furnished by another provider.


The charges were reduced because the service/care was partially furnished by another physician.

Start: 01/01/1995 | Stop: 10/16/2003B22 This payment is adjusted based on the diagnosis.


Start: 01/01/1995 | Last Modified: 09/30/2007D1 Claim/service denied. Level of subluxation is missing or inadequate.

Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D2 Claim lacks the name, strength, or dosage of the drug furnished.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D3


D4 Claim/service does not indicate the period of time for which this will be needed.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D5Claim/service denied. Claim lacks individual lab codes included in the test.


D6 Claim/service denied. Claim did not include patient's medical record for the service.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D8 Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.

D9


D10 Claim/service denied. Completed physician financial relationship form not on file.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 17.

D11 Claim lacks completed pacemaker registration form.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 17.

D12


D13


D14 Claim lacks indication that plan of treatment is on file.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 17.

D15 Claim lacks indication that service was supervised or evaluated by a physician.Start: 01/01/1995 | Stop: 10/16/2003Notes: Use code 17.

D16 Claim lacks prior payer payment information.Start: 01/01/1995 | Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code [N4].

D17 Claim/Service has invalid non-covered days.Start: 01/01/1995 | Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.

D18 Claim/Service has missing diagnosis information.Start: 01/01/1995 | Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.

D19 Claim/Service lacks Physician/Operative or other supporting documentationStart: 01/01/1995 | Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.

D20 Claim/Service missing service/product information.Start: 01/01/1995 | Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.

D21 This (these) diagnosis(es) is (are) missing or are invalidStart: 01/01/1995 | Stop: 06/30/2007

Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.

Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.

Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.

Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.

Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.

D22

Start: 01/27/2008 | Stop: 01/01/2009D23

Start: 11/01/2009 | Stop: 01/01/2012P1

Start: 11/01/2013Notes: This code replaces deactivated code 162

P2


P3


P4


P5


P6


P7


P8


P9


P10


P11


P12

Start: 11/01/2013Notes: This code replaces deactivated code W1

Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code

This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.

Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.

Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only

Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.

Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.

The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.

Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.

No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.

Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.

The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)

Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.

P13


P14


P15


P16


P17


P18


P19


P20


P21

Start: 11/01/2013Notes: This code replaces deactivated code Y1

P22


P23


Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.

The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.

Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.

Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)

Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.

Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.

Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.

Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.

Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Prepaid Denied Claims- Remittance Advice Remark Code (RARC) Dictionary

RARCM1

M2

M3

M4

M5

M6

M7

M8

M9

M10

M11

M12

M13

M14

M15

M16

M16

M17

M18

M19

M20

M21

M22

M23

M24

M25

M26

M27

M28

M29

M30

M31

M32

M33

M34

M35

M36

M37

M38

M39

M40

M40

M41

M42

M43

M44

M45

M46

M47

M48

M49

M50

M51

M52

M53

M54

M55

M56

M56

M57

M58

M59

M60

M61

M62

M63

M64

M65

M66

M67

M68

M69

M70

M71

M72

M73

M74

M75

M76

M77

M78

M79

M80

M81

M82

M83

M84

M85

M86

M87

M88

M89

M89

M90

M91

M92

M93

M94

M95

M96

M97

M98

M99

M100

M101

M102

M103

M104

M105

M106

M106

M107

M108

M109

M110

M111

M112

M113

M114

M115

M116

M117

M118

M119

M120

M121

M122

M123

M124

M125

M126

M127

M128

M129

M130

M131

M132

M133

M134

M135

M136

M137

M138

M139

M140

M141

M142

M143

M144

MA01

MA02

MA03

MA04

MA05

MA06

MA07

MA08

MA09

MA10

MA11

MA12

MA13

MA14

MA15

MA16

MA17

MA18

MA19

MA20

MA21

MA22

MA23

MA24

MA25

MA26

MA27

MA28

MA29

MA30

MA31

MA32

MA33

MA34

MA35

MA36

MA37

MA38

MA39

MA40

MA41

MA42

MA43

MA44

MA45

MA46

MA47

MA48

MA49

MA50

MA51

MA52

MA53

MA54

MA55

MA56

MA57

MA58

MA59

MA60

MA61

MA62

MA63

MA64

MA65

MA66

MA67

MA68

MA69

MA70

MA71

MA72

MA73

MA74

MA75

MA76

MA77

MA78

MA79

MA80

MA81

MA82

MA83

MA84

MA85

MA86

MA87

MA88

MA89

MA90

MA91

MA92

MA93

MA94

MA95

MA96

MA97

MA98

MA98

MA99

MA100

MA101

MA102

MA103

MA104

MA105

MA106

MA107

MA108

MA109

MA110

MA111

MA112

MA113

MA114

MA114

MA115

MA116

MA117

MA118

MA119

MA120

MA121

MA122

MA123

MA124

MA125

MA126

MA127

MA128

MA129

MA130

MA131

MA132

MA133

MA134

N1

N2

N3

N4

N5

N6

N7

N8

N9

N10

N11

N12

N13

N13

N14

N15

N16

N17

N18

N19

N20

N21

N22

N23

N24

N25

N26

N27

N28

N29

N30

N30

N31

N32

N33

N34

N35

N36

N37

N38

N39

N40

N41

N42

N43

N44

N45

N46

N47

N48

N48

N49

N50

N51

N52

N53

N54

N55

N56

N57

N58

N59

N60

N61

N62

N63

N64

N65

N66

N66

N67

N68

N69

N70

N71

N72

N73

N74

N75

N76

N77

N78

N79

N80

N81

N82

N83

N84

N85

N86

N87

N88

N89

N90

N91

N92

N93

N94

N95

N96

N97

N98

N99

N100

N101

N102

N103

N104

N105

N106

N107

N108

N109

N110

N111

N112

N113

N114

N115

N116

N117

N118

N119

N120

N121

N122

N123

N124

N125

N126

N127

N128

N129

N130

N131

N132

N133

N134

N135

N136

N137

N138

N139

N140

N141

N142

N143

N144

N145

N146

N147

N148

N149

N150

N151

N152

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N786

Prepaid Denied Claims- Remittance Advice Remark Code (RARC) Dictionary

RARC DescriptionX-ray not taken within the past 12 months or near enough to the start of treatment.Start: 01/01/1997Not paid separately when the patient is an inpatient.Start: 01/01/1997Equipment is the same or similar to equipment already being used.Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)

Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 03/01/2009Notes: (Modified 4/1/07, 3/1/2009)


Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Equipment purchases are limited to the first or the tenth month of medical necessity.Start: 01/01/1997DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.Start: 01/01/1997Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.Start: 01/01/1997Only one initial visit is covered per specialty per medical group.Start: 01/01/1997 | Last Modified: 06/30/2007Notes: (Modified 6/30/03)

Start: 01/01/1997

Start: 01/01/1997


Alert: This is the last monthly installment payment for this durable medical equipment.

Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.

Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.

No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price.

We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.

Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.

No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.

Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07)


Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing oxygen certification/re-certification.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N234Missing/incomplete/invalid HCPCS.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid place of residence for this service/item provided in a home.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of miles traveled.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing invoice.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)Missing/incomplete/invalid number of doses per vial.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Last Modified: 11/01/2010Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07, 11/1/10)

Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)

Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions.

Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home.

The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.

The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice.

The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office.

Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.Start: 01/01/1997Missing operative note/report.Start: 01/01/1997 | Last Modified: 07/01/2008Notes: (Modified 2/28/03, 7/1/2008) Related to N233Missing pathology report.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 2/28/03) Related to N236Missing radiology report.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 2/28/03) Related to N240

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid UPIN for the ordering/referring/performing provider.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using M68Claim lacks the CLIA certification number.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA120Missing/incomplete/invalid pre-operative photos or visual field results.Start: 01/01/1997 | Stop: 02/05/2005Notes: Consider using N178

Start: 01/01/1997Not covered when the patient is under age 35.Start: 01/01/1997 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)


Start: 01/01/1997 | Last Modified: 07/01/2015Notes: (Modified 2/1/04, 4/1/07, 11/1/09, 11/1/12, 7/1/15) Related to N563Claim must be assigned and must be filed by the practitioner's employer.

Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.

Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service.

This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.

Alert: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges.

Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements.

Start: 01/01/1997We do not pay for this as the patient has no legal obligation to pay for this.Start: 01/01/1997The medical necessity form must be personally signed by the attending physician.Start: 01/01/1997Payment for this service previously issued to you or another provider by another carrier/intermediary.Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using Reason Code 23Missing/incomplete/invalid condition code.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid occurrence code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N299Missing/incomplete/invalid occurrence span code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N300


Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M97Missing/incomplete/invalid value code(s) or amount(s).Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid revenue code(s).Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid procedure code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N301Missing/incomplete/invalid “from” date(s) of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid days or units of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid total charges.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.Start: 01/01/1997Missing/incomplete/invalid payer identifier.Start: 01/01/1997 | Last Modified: 02/28/2003

Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN).

Payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service.

Notes: (Modified 2/28/03)Missing/incomplete/invalid provider identifier.Start: 01/01/1997 | Stop: 06/02/2005Missing/incomplete/invalid claim information. Resubmit claim after corrections.Start: 01/01/1997 | Stop: 02/05/2005Missing/incomplete/invalid “to” date(s) of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing Certificate of Medical Necessity.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 6/30/03) Related to N227We cannot pay for this as the approval period for the FDA clinical trial has expired.Start: 01/01/1997Missing/incomplete/invalid treatment authorization code.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)We do not pay for more than one of these on the same day.Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M86Missing/incomplete/invalid other diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997

Start: 01/01/1997Missing/incomplete/invalid other procedure code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N302Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.Start: 01/01/1997 | Stop: 06/02/2005Paid at the regular rate as you did not submit documentation to justify the modified procedure code.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)

Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 4/1/2007, 8/1/07)Total payment reduced due to overlap of tests billed.Start: 01/01/1997Did not enter full 8-digit date (MM/DD/CCYY).Start: 01/01/1997 | Stop: 10/16/2003Notes: Consider using MA52

One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.

Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.

Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item.

Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04)This service does not qualify for a HPSA/Physician Scarcity bonus payment.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Multiple automated multichannel tests performed on the same day combined for payment.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)Missing/incomplete/invalid diagnosis or condition.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid/inappropriate place of service.Start: 01/01/1997 | Last Modified: 03/14/2014Notes: (Modified 2/28/03, 3/1/2014, 3/14/2014)Missing/incomplete/invalid HCPCS modifier.Start: 01/01/1997 | Stop: 05/18/2006 | Last Modified: 02/28/2003Notes: (Modified 2/28/03,) Consider using Reason Code 4Missing/incomplete/invalid charge.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Not covered when performed during the same session/date as a previously processed service for the patient.Start: 01/01/1997 | Last Modified: 10/31/2002Notes: (Modified 10/31/02)You are required to code to the highest level of specificity.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)Service is not covered when patient is under age 50.Start: 01/01/1997Service is not covered unless the patient is classified as at high risk.Start: 01/01/1997Medical code sets used must be the codes in effect at the time of service.Start: 01/01/1997 | Last Modified: 03/14/2014Notes: (Modified 2/1/04, 3/14/2014)Subjected to review of physician evaluation and management services.Start: 01/01/1997Service denied because payment already made for same/similar procedure within set time frame.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Claim/service(s) subjected to CFO-CAP prepayment review.Start: 01/01/1997We cannot pay for laboratory tests unless billed by the laboratory that did the work.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using Reason Code B20Not covered more than once under age 40.

The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.

Start: 01/01/1997Not covered more than once in a 12 month period.Start: 01/01/1997Lab procedures with different CLIA certification numbers must be billed on separate claims.Start: 01/01/1997Services subjected to review under the Home Health Medical Review Initiative.Start: 01/01/1997 | Stop: 08/01/2004Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.Start: 01/01/1997Information supplied does not support a break in therapy. A new capped rental period will not begin.Start: 01/01/1997Services subjected to Home Health Initiative medical review/cost report audit.Start: 01/01/1997

Start: 01/01/1997

Start: 01/01/1997

Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M99Missing/incomplete/invalid Universal Product Number/Serial Number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997

Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M78Service not performed on equipment approved by the FDA for this purpose.Start: 01/01/1997

Start: 01/01/1997

Start: 01/01/1997

Start: 01/01/1997

Start: 01/01/1997 | Stop: 01/31/2004

The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.

Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.

Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN.

We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.

Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier.

Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.

Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.

Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.

Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service.

Notes: Consider using MA 31Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.Start: 01/01/1997Missing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test.Start: 01/01/1997 | Stop: 06/02/2005

Start: 01/01/1997Missing/incomplete/invalid provider identifier for the provider from whom you purchased interpretation services.Start: 01/01/1997 | Stop: 06/02/2005We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.Start: 01/01/1997



Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 8/1/06, 11/5/07)This item is denied when provided to this patient by a non-contract or non-demonstration supplier.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/2007)

Start: 01/01/1997 | Last Modified: 03/08/2011Notes: (Modified 2/1/04, 3/15/11)Not covered unless submitted via electronic claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Letter to follow containing further information.Start: 01/01/1997 | Stop: 01/01/2011 | Last Modified: 11/01/2009Notes: Consider using N202Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 2/28/03, 4/1/04)

Start: 01/01/1997 | Stop: 06/02/2005We pay for this service only when performed with a covered cryosurgical ablation.Start: 01/01/1997Missing/incomplete/invalid level of subluxation.Start: 01/01/1997 | Last Modified: 02/28/2006Notes: (Modified 2/28/03)

We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.

Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.

Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.

This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.

Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program.

Missing/incomplete/invalid provider identifier for the substituting physician who furnished the service(s) under a reciprocal billing or locum tenens arrangement.

Missing/incomplete/invalid name, strength, or dosage of the drug furnished.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing indication of whether the patient owns the equipment that requires the part or supply.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N230Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid individual lab codes included in the test.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing patient medical record for this service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N237Missing/incomplete/invalid date of the patient’s last physician visit.Start: 01/01/1997 | Stop: 06/02/2005Missing/incomplete/invalid indicator of x-ray availability for review.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 2/28/03, 6/30/03)

Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N231Missing physician financial relationship form.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N239Missing pacemaker registration form.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N235Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.Start: 01/01/1997Performed by a facility/supplier in which the provider has a financial interest.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing/incomplete/invalid plan of treatment.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Part B coinsurance under a demonstration project or pilot program.Start: 01/01/1997 | Last Modified: 11/01/2012Notes: (Modified 11/1/12)

Start: 01/01/1997

Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.

Denied services exceed the coverage limit for the demonstration.Start: 01/01/1997Service not covered until after the patient’s 50th birthday, i.e., no coverage prior to the day after the 50th birthdayStart: 01/01/1997 | Stop: 01/30/2004Notes: Consider using M82Missing physician certified plan of care.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N238Missing American Diabetes Association Certificate of Recognition.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N226The provider must update license information with the payer.Start: 01/01/1997 | Last Modified: 12/01/2006Notes: (Modified 12/1/06)Pre-/post-operative care payment is included in the allowance for the surgery/procedure.Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 4/1/07)

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 12/29/05, 8/1/06, 4/1/07)

Start: 01/01/1997 | Stop: 10/01/2006 | Last Modified: 11/18/2005Notes: Consider using MA02 (Modified 10/31/02, 6/30/03, 8/1/05, 11/18/05)

Start: 01/01/1997Incorrect admission date patient status or type of bill entry on claim.Start: 01/01/1997 | Stop: 10/16/2003Notes: Consider using MA30, MA40 or MA43Missing/incomplete/invalid beginning and/or ending date(s).Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA31



Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.

Alert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice.

If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied, including reopened appeals if you received a revised decision. You must appeal each claim on time.

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

Alert: The claim information has also been forwarded to Medicaid for review.

Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.



Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M32

Start: 01/01/1997




Start: 01/01/1997

Start: 01/01/1997



Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)SSA records indicate mismatch with name and sex.Start: 01/01/1997Payment of less than $1.00 suppressed.Start: 01/01/1997

Alert: Claim submitted as unassigned but processed as assigned in accordance with our current assignment/participation agreement.

Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.

Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources.

You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).

Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services.

Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.

The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.

We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.

Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.

Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.

Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.

Demand bill approved as result of medical review.Start: 01/01/1997Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)A patient may not elect to change a hospice provider more than once in a benefit period.Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid entitlement number or name shown on the claim.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid provider name, city, state, or zip code.Start: 01/01/1997 | Stop: 06/02/2005Missing/incomplete/invalid type of bill.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid beginning and ending dates of the period billed.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of covered days during the billing period.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid noncovered days during the billing period.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of coinsurance days during the billing period.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of lifetime reserve days.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient name.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient's address.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid birth date.Start: 01/01/1997 | Stop: 06/02/2005

Alert: Our records indicate that you were previously informed of this rule.

Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice.

Missing/incomplete/invalid gender.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid admission date.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid admission type.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid admission source.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient status.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)




Start: 01/01/1997Missing/incomplete/invalid name or address of responsible party or primary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA76Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.Start: 01/01/1997 | Last Modified: 03/01/2014Notes: (Modified 2/28/03, 3/1/2014)Missing/incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory.Start: 01/01/1997 | Stop: 02/05/2005Notes: Consider using MA120Missing/incomplete/invalid date.Start: 01/01/1997 | Stop: 06/02/2005Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)Physician certification or election consent for hospice care not received timely.Start: 01/01/1997

Alert: No appeal rights. Adjudicative decision based on law.

Alert: As previously advised, a portion or all of your payment is being held in a special account.

Alert: The new information was considered but additional payment will not be issued.

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.

Missing/incomplete/invalid six-digit provider identifier for home health agency or hospice for physician(s) performing care plan oversight services.

Start: 01/01/1997

Start: 01/01/1997Patient submitted written request to revoke his/her election for religious non-medical health care services.Start: 01/01/1997Missing/incomplete/invalid release of information indicator.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid patient relationship to insured.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid social security number or health insurance claim number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 4/1/07, 8/1/07)Missing/incomplete/invalid principal diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997Missing/incomplete/invalid admitting diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid principal procedure code.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N303


Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid remarks.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.

Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.

Alert: This is a telephone review decision.

Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.

Alert: Correction to a prior claim.

Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.

Missing/incomplete/invalid provider representative signature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid provider representative signature date.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)


Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 07/01/2015Notes: (Modified 7/1/15)Missing/incomplete/invalid patient or authorized representative signature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)



Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using MA59Billed in excess of interim rate.Start: 01/01/1997

Start: 01/01/1997Missing/incomplete/invalid provider/supplier signature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997 | Stop: 06/02/2005Did not indicate whether we are the primary or secondary payer.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)

Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the patient on this notice.

Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.

Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or returned.

Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.

Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient’s payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice.

The patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient.

Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.

Missing/incomplete/invalid provider/supplier billing number/identifier or billing name, address, city, state, zip code, or phone number.

Start: 01/01/1997

Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA92Missing/incomplete/invalid group or policy number of the insured for the primary coverage.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA92Missing/incomplete/invalid insured's name for the primary payer.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using MA92Missing/incomplete/invalid insured's address and/or telephone number for the primary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient's relationship to the insured for the primary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid employment status code for the primary insured.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03).

Start: 01/01/1997 | Last Modified: 07/01/2015Notes: (Modified 7/1/15)Missing plan information for other insurance.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04) Related to N245Non-PIP (Periodic Interim Payment) claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)

Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Reactivated 4/1/04, Modified 8/1/05)

Start: 01/01/1997 | Stop: 01/01/2004 | Last Modified: 02/28/2003Notes: (Deactivated 2/28/2003) (Erroneous description corrected 9/2/2008) Consider using M51

Start: 01/01/1997Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.Start: 01/01/1997 | Last Modified: 02/29/2008Notes: (Modified 2/29/08)

Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary.

Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.

Our records indicate that a primary payer exists (other than ourselves); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the PlanID when effective.

Alert: This determination is the result of the appeal you filed.

Did not enter the statement “Attending physician not hospice employee” on the claim form to certify that the rendering physician is not an employee of the hospice.

A not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA-1500.

Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.

Start: 01/01/1997 | Stop: 10/16/2003Notes: Consider using MA97Missing/incomplete/invalid Medigap information.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid date of current illness or symptoms.Start: 01/01/1997 | Last Modified: 03/14/2014Notes: (Modified 2/28/03, 3/30/05, 3/14/2014)

Start: 01/01/1997 | Stop: 01/01/2011 | Last Modified: 06/30/2003Notes: Consider using N538Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider.Start: 01/01/1997 | Stop: 08/01/2004Notes: Consider using M68Hemophilia Add On.Start: 01/01/1997Missing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician.Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using M128 or M57Missing/incomplete/invalid provider number for this place of service.Start: 01/01/1997 | Stop: 06/02/2005PIP (Periodic Interim Payment) claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Paper claim contains more than three separate data items in field 19.Start: 01/01/1997Paper claim contains more than one data item in field 23.Start: 01/01/1997Claim processed in accordance with ambulatory surgical guidelines.Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid group practice information.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/1997Missing/incomplete/invalid information on where the services were furnished.

A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents.

Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.

Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.



Start: 01/01/1997Notes: (Reactivated 4/1/04)This claim has been assessed a $1.00 user fee.Start: 01/01/1997

Start: 01/01/1997 | Last Modified: 11/01/2014Provider level adjustment for late claim filing applies to this claim.Start: 01/01/1997 | Stop: 05/01/2008 | Last Modified: 11/05/2007Notes: Consider using Reason Code B4Missing/incomplete/invalid CLIA certification number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid x-ray date.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Missing/incomplete/invalid initial treatment date.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Your center was not selected to participate in this study, therefore, we cannot pay for these services.Start: 01/01/1997Processed for IME only.Start: 01/01/1997 | Stop: 01/31/2004Notes: Consider using Reason Code 74Per legislation governing this program, payment constitutes payment in full.Start: 01/01/1997Pancreas transplant not covered unless kidney transplant performed.Start: 10/12/2001Reserved for future use.Start: 10/12/2001 | Stop: 06/02/2005Missing/incomplete/invalid FDA approval number.Start: 10/12/2001 | Last Modified: 03/30/2005Notes: (Modified 2/28/03, 3/30/05)This provider was not certified for this procedure on this date of service.Start: 10/12/2001 | Stop: 01/31/2004 | Last Modified: 01/31/2004Notes: Consider using MA120 and Reason Code B7

Start: 10/12/2001

Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).

Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution.

Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Coinsurance and/or deductible are applicable.

Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Start: 10/12/2001Adjustment to the pre-demonstration rate.Start: 10/12/2001Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.Start: 10/12/2001Missing/incomplete/invalid provider number of the facility where the patient resides.Start: 10/12/2001

Start: 01/01/2000 | Last Modified: 07/15/2013Notes: (Modified 2/28/03, 4/1/07, 7/15/13)This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.Start: 01/01/2000Missing consent form.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N228Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.Start: 01/01/2000 | Last Modified: 03/06/2012Notes: (Modified 2/28/03, 3/6/2012)EOB received from previous payer. Claim not on file.Start: 01/01/2000



Start: 01/01/2000Adjustment represents the estimated amount a previous payer may pay.Start: 01/01/2000 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)

Start: 01/01/2000 | Last Modified: 03/01/2015Notes: (Modified 10/31/02, 7/1/08, 7/15/13, 3/1/2015)Denial reversed because of medical review.Start: 01/01/2000

Start: 01/01/2000 | Last Modified: 08/01/2007Notes: (Modified 8/1/07)Payment based on professional/technical component modifier(s).

Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.

Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes.

Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.

Alert: Processing of this claim/service has included consideration under Major Medical provisions.

Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.

Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.

Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.

Start: 01/01/2000Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.Start: 01/01/2000 | Stop: 10/01/2007Notes: Consider using Reason Code 45Services for a newborn must be billed separately.Start: 01/01/2000Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.Start: 01/01/2000Per admission deductible.Start: 01/01/2000 | Stop: 08/01/2004Notes: Consider using Reason Code 1Payment based on the Medicare allowed amount.Start: 01/01/2000 | Stop: 01/31/2004Notes: Consider using N14Procedure code incidental to primary procedure.Start: 01/01/2000Service not payable with other service rendered on the same date.Start: 01/01/2000


Start: 01/01/2000 | Last Modified: 07/01/2015Notes: (Modified 10/31/02, 2/28/03, 7/1/15)

Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 8/13/01, 4/1/07)Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/2000Missing itemized bill/statement.Start: 01/01/2000 | Last Modified: 07/01/2008Notes: (Modified 2/28/03, 7/1/2008) Related to N232Missing/incomplete/invalid treatment number.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Consent form requirements not fulfilled.Start: 01/01/2000Missing documentation/orders/notes/summary/report/chart.Start: 01/01/2000 | Stop: 03/01/2016 | Last Modified: 03/01/2014

Patient ineligible for this service.

Alert: Your line item has been separated into multiple lines to expedite handling.

Alert: This procedure code was added/changed because it more accurately describes the services rendered.

Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.

This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.

Notes: (Modified 2/28/03, 8/1/05, 3/1/2014) Related to N225, Explicit RARCs have been approved, this non-specific RARC will be deactivated in March 2016.

Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing/incomplete/invalid prescribing provider identifier.Start: 01/01/2000 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Claim must be submitted by the provider who rendered the service.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)No record of health check prior to initiation of treatment.Start: 01/01/2000Incorrect claim form/format for this service.Start: 01/01/2000 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)Program integrity/utilization review decision.Start: 01/01/2000Claim must meet primary payer’s processing requirements before we can consider payment.Start: 01/01/2000Missing/incomplete/invalid tooth number/letter.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid place of service.Start: 01/01/2000 | Stop: 02/05/2005Notes: Consider using M77Procedure code is not compatible with tooth number/letter.Start: 01/01/2000Missing radiology film(s)/image(s).Start: 01/01/2000 | Last Modified: 07/01/2008Notes: (Modified 2/1/04, 7/1/08) Related to N242Authorization request denied.Start: 01/01/2000 | Stop: 10/16/2003Notes: Consider using Reason Code 39Missing mental health assessment.Start: 01/01/2000 | Last Modified: 11/01/2014Bed hold or leave days exceeded.Start: 01/01/2000

Start: 01/01/2000 | Stop: 10/16/2003Notes: Consider using Reason Code 137Payment based on authorized amount.Start: 01/01/2000Missing/incomplete/invalid admission hour.Start: 01/01/2000Claim conflicts with another inpatient stay.Start: 01/01/2000Claim information does not agree with information received from other insurance carrier.

Payer’s share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority.

Start: 01/01/2000Court ordered coverage information needs validation.Start: 01/01/2000Missing/incomplete/invalid discharge information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Electronic interchange agreement not on file for provider/submitter.Start: 01/01/2000Patient not enrolled in the billing provider's managed care plan on the date of service.Start: 01/01/2000Missing/incomplete/invalid point of pick-up address.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Claim information is inconsistent with pre-certified/authorized services.Start: 01/01/2000Procedures for billing with group/referring/performing providers were not followed.Start: 01/01/2000Procedure code billed is not correct/valid for the services billed or the date of service billed.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid prescribing date.Start: 01/01/2000 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N304Missing/incomplete/invalid patient liability amount.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 01/01/2000 | Last Modified: 11/01/2015Notes: (Modified 4/1/07, 11/1/09, 11/1/2015)A valid NDC is required for payment of drug claims effective October 02.Start: 01/01/2000 | Stop: 01/31/2004Notes: Consider using M119Rebill services on separate claims.Start: 01/01/2000Dates of service span multiple rate periods. Resubmit separate claims.Start: 01/01/2000 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)Rebill services on separate claim lines.Start: 01/01/2000The “from” and “to” dates must be different.Start: 01/01/2000Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid documentation.Start: 01/01/2000 | Stop: 02/05/2005

Alert: Please refer to your provider manual for additional program and provider information.

Notes: Consider using N29 or N225.

Start: 01/01/2000

Start: 01/01/2000

Start: 01/01/2000 | Last Modified: 11/01/2015Notes: (Modified 6/30/03, 7/1/12, 11/1/2015)Consolidated billing and payment applies.Start: 01/01/2000 | Last Modified: 11/05/2007Notes: (Modified 2/28/02, 11/5/07)

Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 2/21/02, 6/30/03)PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)

Start: 01/01/2000 | Stop: 01/31/2004Notes: Consider using MA101 or N200Resubmit with multiple claims, each claim covering services provided in only one calendar month.Start: 01/01/2000Missing/incomplete/invalid tooth surface information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of riders.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid designated provider number.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)The necessary components of the child and teen checkup (EPSDT) were not completed.Start: 01/01/2000Service billed is not compatible with patient location information.Start: 01/01/2000Missing/incomplete/invalid prenatal screening information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient’s admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.

Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.

Alert: PPS (Prospective Payment System) code changed by claims processing system.

Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.

A Skilled Nursing Facility is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents.

Procedure billed is not compatible with tooth surface code.Start: 01/01/2000

Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.

Start: 01/01/2000No appeal rights. Adjudicative decision based on the provisions of a demonstration project.Start: 01/01/2000



Start: 01/01/2000Home use of biofeedback therapy is not covered.Start: 01/01/2000


Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Covered only when performed by the attending physician.Start: 01/01/2000Services not included in the appeal review.Start: 01/01/2000This facility is not certified for digital mammography.Start: 01/01/2000

Start: 01/01/2000Claim/Service denied because a more specific taxonomy code is required for adjudication.Start: 01/01/2000This provider type/provider specialty may not bill this service.Start: 07/31/2001 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 08/24/2001

Start: 08/24/2001

Alert: Further installment payments are forthcoming.

Alert: This is the final installment payment.

A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.

Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care.

Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.

A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.

Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.

Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.

Start: 08/24/2001

Start: 08/24/2001PPS (Prospect Payment System) code corrected during adjudication.Start: 09/14/2001 | Stop: 11/01/2016 | Last Modified: 11/01/2015Notes: (Modified 6/30/03, 11/1/2015)

Start: 10/31/2001 | Stop: 01/31/2004 | Last Modified: 03/14/2014Notes: Consider using MA105 (Modified 3/14/2014)

Start: 10/31/2001 | Stop: 07/01/2016 | Last Modified: 11/01/2013



Start: 01/29/2002

Start: 01/31/2002

Start: 01/31/2002Missing/incomplete/invalid upgrade information.Start: 01/31/2002 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)

Start: 02/28/2002 | Last Modified: 07/01/2015Notes: (Modified 3/1/2009, 7/1/15)This facility is not certified for film mammography.Start: 02/28/2002

Start: 02/28/2002

Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Additional information is needed in order to process this claim. Please resubmit the claim with the identification number of the provider where this service took place. The Medicare number of the site of service provider should be preceded with the letters 'HSP' and entered into item #32 on the claim form. You may bill only one site of service provider number per claim.

This claim has been denied without reviewing the medical/dental record because the requested records were not received or were not received timely.

Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.

This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.

This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing.

Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.

Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.

Alert: This claim/service was chosen for complex review.

No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.

This claim is excluded from your electronic remittance advice.Start: 02/28/2002Only one initial visit is covered per physician, group practice or provider.Start: 04/16/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)

Start: 05/30/2002


Start: 06/30/2002 | Last Modified: 11/01/2016Notes: (Modified 11/1/2016)This service is paid only once in a patient’s lifetime.Start: 07/30/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)This service is not paid if billed more than once every 28 days.Start: 07/30/2002



Start: 09/09/2002 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 6/30/03)Add-on code cannot be billed by itself.Start: 09/12/2002 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)


Start: 09/26/2002

During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.

This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.

Alert: This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency’s (HHA’s) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.

This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.

Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.

Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.

Alert: This is a split service and represents a portion of the units from the originally submitted service.

Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.

Start: 09/26/2002 | Last Modified: 08/01/2005Notes: (Modified 8/1/05. Also refer to N356)

Start: 10/17/2002

Start: 10/31/2007 | Last Modified: 08/01/2004Notes: (Modified 8/1/04This amount represents the prior to coverage portion of the allowance.Start: 10/31/2002Not eligible due to the patient's age.Start: 10/31/2002 | Last Modified: 08/01/2007Notes: (Modified 8/1/07)Consult plan benefit documents/guidelines for information about restrictions for this service.Start: 10/31/2002 | Last Modified: 11/01/2009Notes: (Modified 4/1/07, 7/1/08, 11/1/09)Total payments under multiple contracts cannot exceed the allowance for this service.Start: 10/31/2002



Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Record fees are the patient's responsibility and limited to the specified co-payment.Start: 10/31/2002



Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice.

The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in §§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office.

Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.

This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.

Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.

Alert: Services for predetermination and services requesting payment are being processed separately.

Alert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service.

Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.

Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority.



Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The patient was not residing in a long-term care facility during all or part of the service dates billed.Start: 10/31/2002The original claim was denied. Resubmit a new claim, not a replacement claim.Start: 10/31/2002The patient was not in a hospice program during all or part of the service dates billed.Start: 10/31/2002The rate changed during the dates of service billed.Start: 10/31/2002Missing/incomplete/invalid provider identifier for this place of service.Start: 10/31/2002 | Stop: 06/02/2005Missing screening document.Start: 10/31/2002 | Last Modified: 08/01/2004Notes: (Modified 8/1/04) Related to N243

Start: 10/31/2002Missing/incomplete/invalid date of last menstrual period.Start: 10/31/2002Rebill all applicable services on a single claim.Start: 10/31/2002Missing/incomplete/invalid model number.Start: 10/31/2002Telephone contact services will not be paid until the face-to-face contact requirement has been met.Start: 10/31/2002Missing/incomplete/invalid replacement claim information.Start: 10/31/2002Missing/incomplete/invalid room and board rate.Start: 10/31/2002

Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review.

Alert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.

Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.

Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.

Alert: This payment was delayed for correction of provider's mailing address.



Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Transportation to/from this destination is not covered.Start: 02/28/2003 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)Transportation in a vehicle other than an ambulance is not covered.Start: 02/28/2003Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.Start: 02/28/2003The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.Start: 02/28/2003 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)This drug/service/supply is covered only when the associated service is covered.Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Medical record does not support code billed per the code definition.Start: 02/28/2003Transportation to/from this destination is not covered.Start: 02/28/2003 | Stop: 01/31/2004Notes: Consider using N157Transportation in a vehicle other than an ambulance is not covered.Start: 02/28/2003 | Stop: 01/31/2004Notes: Consider using N158)Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.Start: 02/28/2003 | Stop: 01/31/2004Notes: Consider using N159Charges exceed the post-transplant coverage limit.Start: 02/28/2003The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.Start: 02/28/2003 | Stop: 01/31/2004Notes: Consider using N160This drug/service/supply is covered only when the associated service is covered.Start: 02/28/2003 | Stop: 01/31/2004Notes: Consider using N161A new/revised/renewed certificate of medical necessity is needed.Start: 02/28/2003

Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.

Alert: The patient is responsible for the difference between the approved treatment and the elective treatment.

Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future.

Payment for repair or replacement is not covered or has exceeded the purchase price.Start: 02/28/2003The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.Start: 02/28/2003No qualifying hospital stay dates were provided for this episode of care.Start: 02/28/2003

Start: 02/28/2003Missing review organization approval.Start: 02/28/2003 | Last Modified: 02/29/2008Notes: (Modified 8/1/04, 2/29/08) Related to N241

Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 6/30/03, 4/1/07)Missing pre-operative images/visual field results.Start: 02/28/2003 | Last Modified: 11/01/2013Notes: (Modified 8/1/04, 11/1/13) Related to N244

Start: 02/28/2003This item or service does not meet the criteria for the category under which it was billed.Start: 02/28/2003Additional information is required from another provider involved in this service.Start: 02/28/2003 | Last Modified: 12/01/2006Notes: (Modified 12/1/06)This claim/service must be billed according to the schedule for this plan.Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Rebill technical and professional components separately.Start: 02/28/2003


Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The approved level of care does not match the procedure code submitted.

This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'.

Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.

Alert: We did not send this claim to patient’s other insurer. They have indicated no additional payment can be made.

Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.

Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.

Alert: Do not resubmit this claim/service.

Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.

Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.

Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing contract indicator.Start: 02/28/2003 | Last Modified: 08/01/2004Notes: (Modified 8/1/04) Related to N229The provider must update insurance information directly with payer.Start: 02/28/2003Patient is a Medicaid/Qualified Medicare Beneficiary.Start: 02/28/2003

Start: 02/28/2003 | Last Modified: 11/01/2015Notes: (Modified 11/1/2015)Technical component not paid if provider does not own the equipment used.Start: 02/25/2003The technical component must be billed separately.Start: 02/25/2003

Start: 02/25/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The subscriber must update insurance information directly with payer.Start: 02/25/2003Rendering provider must be affiliated with the pay-to provider.Start: 02/25/2003Additional payment/recoupment approved based on payer-initiated review/audit.Start: 02/25/2003 | Last Modified: 08/01/2006Notes: (Modified 8/1/06)The professional component must be billed separately.Start: 02/25/2003

A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.

Start: 02/25/2003 | Stop: 01/01/2011Notes: Consider using N538

Start: 06/30/2003 | Last Modified: 11/01/2015Notes: (Modified 4/1/07, 11/1/09, 3/14/2014, 11/1/2015)Missing/incomplete/invalid anesthesia time/units.Start: 06/30/2003 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Services under review for possible pre-existing condition. Send medical records for prior 12 monthsStart: 06/30/2003Information provided was illegible.Start: 06/30/2003 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)The supporting documentation does not match the information sent on the claim.

Alert: This service has been paid as a one-time exception to the plan's benefit restrictions.

Alert: Specific federal/state/local program may cover this service through another payer.

Alert: Patient eligible to apply for other coverage which may be primary.

Alert: Additional information/explanation will be sent separately.

Start: 06/30/2003 | Last Modified: 03/06/2012Notes: (Modified 3/6/12)Missing/incomplete/invalid weight.Start: 06/30/2003 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)Missing/incomplete/invalid DRG code.Start: 06/30/2003 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing/incomplete/invalid taxpayer identification number (TIN).Start: 06/30/2003 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)


Start: 06/30/2003 | Last Modified: 03/14/2014Notes: (Modified 4/1/07, 3/14/2014)Charges processed under a Point of Service benefit .Start: 02/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information.Start: 04/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing/incomplete/invalid history of the related initial surgical procedure(s).Start: 04/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)

Start: 04/01/2004 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.Start: 04/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/1/2010, 3/14/2014)We pay only one site of service per provider per claim.Start: 08/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)

Start: 08/01/2004Payment based on previous payer's allowed amount.Start: 08/01/2004

Start: 08/01/2004 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing Admitting History and Physical report.Start: 08/01/2004

Alert: You may appeal this decision.

Alert: You may not appeal this decision.

Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.

You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.

Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute.

Incomplete/invalid Admitting History and Physical report.Start: 08/01/2004Missing documentation of benefit to the patient during initial treatment period.Start: 08/01/2004Incomplete/invalid documentation of benefit to the patient during initial treatment period.Start: 08/01/2004Incomplete/invalid documentation/orders/notes/summary/report/chart.Start: 08/01/2004 | Stop: 03/01/2016 | Last Modified: 03/01/2014

Incomplete/invalid American Diabetes Association Certificate of Recognition.Start: 08/01/2004Incomplete/invalid Certificate of Medical Necessity.Start: 08/01/2004Incomplete/invalid consent form.Start: 08/01/2004Incomplete/invalid contract indicator.Start: 08/01/2004Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.Start: 08/01/2004

Start: 08/01/2004Incomplete/invalid itemized bill/statement.Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid operative note/report.Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid oxygen certification/re-certification.Start: 08/01/2004Incomplete/invalid pacemaker registration form.Start: 08/01/2004Incomplete/invalid pathology report.Start: 08/01/2004Incomplete/invalid patient medical record for this service.Start: 08/01/2004Incomplete/invalid physician certified plan of care.Start: 08/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Incomplete/invalid physician financial relationship form.Start: 08/01/2004Incomplete/invalid radiology report.Start: 08/01/2004Incomplete/invalid review organization approval.Start: 08/01/2004 | Last Modified: 02/29/2008

Notes: (Modified 8/1/05, 3/1/2014) Explicit RARCs have been approved, this non-specific RARC will be deactivated in March 2016.

Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Notes: (Modified 2/29/08)Incomplete/invalid radiology film(s)/image(s).Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid/not approved screening document.Start: 08/01/2004Incomplete/Invalid pre-operative images/visual field results.Start: 08/01/2004 | Last Modified: 11/01/2013Notes: (Modified 11/1/2013)Incomplete/invalid plan information for other insurance .Start: 08/01/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)State regulated patient payment limitations apply to this service.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon taxonomy.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon name.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon primary identifier.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon secondary identifier.Start: 12/02/2004Missing/incomplete/invalid attending provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid attending provider name.Start: 12/02/2004Missing/incomplete/invalid attending provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid attending provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier name.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier primary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier address.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier secondary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier contact information.Start: 12/02/2004Missing/incomplete/invalid operating provider name.Start: 12/02/2004Missing/incomplete/invalid operating provider primary identifier.

Start: 12/02/2004Missing/incomplete/invalid operating provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider name.Start: 12/02/2004Missing/incomplete/invalid ordering provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider address.Start: 12/02/2004Missing/incomplete/invalid ordering provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider contact information.Start: 12/02/2004Missing/incomplete/invalid other provider name.Start: 12/02/2004Missing/incomplete/invalid other provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid other provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid other payer attending provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer operating provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer other provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer purchased service provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer referring provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer rendering provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer service facility provider identifier.Start: 12/02/2004Missing/incomplete/invalid pay-to provider name.Start: 12/02/2004Missing/incomplete/invalid pay-to provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid pay-to provider address.Start: 12/02/2004Missing/incomplete/invalid pay-to provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid purchased service provider identifier.Start: 12/02/2004Missing/incomplete/invalid referring provider taxonomy.Start: 12/02/2004

Missing/incomplete/invalid referring provider name.Start: 12/02/2004Missing/incomplete/invalid referring provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid referring provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid rendering provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid rendering provider name.Start: 12/02/2004Missing/incomplete/invalid rendering provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid rendering provider secondary identifier.Start: 12/02/2004 | Last Modified: 11/01/2010Missing/incomplete/invalid service facility name.Start: 12/02/2004Missing/incomplete/invalid service facility primary identifier.Start: 12/02/2004Missing/incomplete/invalid service facility primary address.Start: 12/02/2004Missing/incomplete/invalid service facility secondary identifier.Start: 12/02/2004Missing/incomplete/invalid supervising provider name.Start: 12/02/2004Missing/incomplete/invalid supervising provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid supervising provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid occurrence date(s).Start: 12/02/2004Missing/incomplete/invalid occurrence span date(s).Start: 12/02/2004Missing/incomplete/invalid procedure date(s).Start: 12/02/2004Missing/incomplete/invalid other procedure date(s).Start: 12/02/2004Missing/incomplete/invalid principal procedure date.Start: 12/02/2004Missing/incomplete/invalid dispensed date.Start: 12/02/2004Missing/incomplete/invalid injury/accident date.Start: 12/02/2004 | Last Modified: 11/01/2016Notes: (Modified 11/1/2016)Missing/incomplete/invalid acute manifestation date.Start: 12/02/2004

Missing/incomplete/invalid adjudication or payment date.Start: 12/02/2004Missing/incomplete/invalid appliance placement date.Start: 12/02/2004Missing/incomplete/invalid assessment date.Start: 12/02/2004Missing/incomplete/invalid assumed or relinquished care date.Start: 12/02/2004Missing/incomplete/invalid authorized to return to work date.Start: 12/02/2004Missing/incomplete/invalid begin therapy date.Start: 12/02/2004Missing/incomplete/invalid certification revision date.Start: 12/02/2004Missing/incomplete/invalid diagnosis date.Start: 12/02/2004Missing/incomplete/invalid disability from date.Start: 12/02/2004Missing/incomplete/invalid disability to date.Start: 12/02/2004Missing/incomplete/invalid discharge hour.Start: 12/02/2004Missing/incomplete/invalid discharge or end of care date.Start: 12/02/2004Missing/incomplete/invalid hearing or vision prescription date.Start: 12/02/2004Missing/incomplete/invalid Home Health Certification Period.Start: 12/02/2004Missing/incomplete/invalid last admission period.Start: 12/02/2004Missing/incomplete/invalid last certification date.Start: 12/02/2004Missing/incomplete/invalid last contact date.Start: 12/02/2004Missing/incomplete/invalid last seen/visit date.Start: 12/02/2004Missing/incomplete/invalid last worked date.Start: 12/02/2004Missing/incomplete/invalid last x-ray date.Start: 12/02/2004Missing/incomplete/invalid other insured birth date.Start: 12/02/2004Missing/incomplete/invalid Oxygen Saturation Test date.Start: 12/02/2004Missing/incomplete/invalid patient birth date.

Start: 12/02/2004Missing/incomplete/invalid patient death date.Start: 12/02/2004Missing/incomplete/invalid physician order date.Start: 12/02/2004Missing/incomplete/invalid prior hospital discharge date.Start: 12/02/2004Missing/incomplete/invalid prior placement date.Start: 12/02/2004Missing/incomplete/invalid re-evaluation date.Start: 12/02/2004 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing/incomplete/invalid referral date.Start: 12/02/2004Missing/incomplete/invalid replacement date.Start: 12/02/2004Missing/incomplete/invalid secondary diagnosis date.Start: 12/02/2004Missing/incomplete/invalid shipped date.Start: 12/02/2004Missing/incomplete/invalid similar illness or symptom date.Start: 12/02/2004Missing/incomplete/invalid subscriber birth date.Start: 12/02/2004Missing/incomplete/invalid surgery date.Start: 12/02/2004Missing/incomplete/invalid test performed date.Start: 12/02/2004Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.Start: 12/02/2004Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.Start: 12/02/2004Date range not valid with units submitted.Start: 03/30/2005Missing/incomplete/invalid oral cavity designation code.Start: 03/30/2005

Start: 03/30/2005You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.Start: 08/01/2005The administration method and drug must be reported to adjudicate this service.Start: 08/01/2005


Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.

Notes: (Modified 7/1/08)Service date outside of the approved treatment plan service dates.Start: 08/01/2005


Start: 08/01/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Incomplete/invalid invoice.Start: 08/01/2005 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)

Start: 08/01/2005 | Last Modified: 04/01/2007Notes: (Modified 11/18/05, Modified 4/1/07)Not covered when performed with, or subsequent to, a non-covered service.Start: 08/01/2005 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)

Start: 11/18/2005

Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid height.Start: 11/18/2005

Alert: There are no scheduled payments for this service. Submit a claim for each patient visit.

Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.

Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service.

If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position.

If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision.

The law also permits you to request an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination.

The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days

Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.

Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.

Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.

Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Payment adjusted based on multiple diagnostic imaging procedure rulesStart: 11/18/2005 | Stop: 10/01/2007 | Last Modified: 12/01/2006Notes: (Modified 12/1/06) Consider using Reason Code 59The number of Days or Units of Service exceeds our acceptable maximum.Start: 11/18/2005


Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)This procedure code is not payable. It is for reporting/information purposes only.Start: 04/01/2006 | Stop: 07/01/2014Notes: Consider Using CARC 246 or N620

Start: 04/01/2006

Start: 04/01/2006 | Last Modified: 07/01/2008Notes: (Modified 4/1/07, 11/5/07, 7/1/08)You must appeal the determination of the previously adjudicated claim.Start: 04/01/2006

Start: 04/01/2006Billing exceeds the rental months covered/approved by the payer.Start: 08/01/2006

Start: 08/01/2006Only reasonable and necessary maintenance/service charges are covered.Start: 08/01/2006

Start: 12/01/2006Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.Start: 12/01/2006Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.Start: 12/01/2006Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.Start: 12/01/2006Payment based on a processed replacement claim.Start: 12/01/2006 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)Missing/incomplete/invalid prescription quantity.Start: 12/01/2006

Alert: in the near future we are implementing new policies/procedures that would affect this determination.

Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts.

Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.

Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.

Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.

Alert: title of this equipment must be transferred to the patient.

It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.

Claim level information does not match line level information.Start: 12/01/2006The original claim has been processed, submit a corrected claim.Start: 04/01/2007

Start: 04/01/2007 | Last Modified: 07/01/2015Notes: (Modified 7/1/15)Missing/incomplete/invalid patient identifier.Start: 04/01/2007Not covered when deemed cosmetic.Start: 04/01/2007 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)Records indicate that the referenced body part/tooth has been removed in a previous procedure.Start: 04/01/2007Notification of admission was not timely according to published plan procedures.Start: 04/01/2007 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)


Start: 04/01/2007 | Last Modified: 03/01/2009Notes: (Modified 3/1/2009)Missing/incomplete/invalid prescription number.Start: 08/01/2007 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Duplicate prescription number submitted.Start: 08/01/2007This service/report cannot be billed separately.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Missing emergency department records.Start: 08/01/2007Incomplete/invalid emergency department records.Start: 08/01/2007Missing progress notes/report.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid progress notes/report.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Missing laboratory report.Start: 08/01/2007

Alert: Consult our contractual agreement for restrictions/billing/payment information related to these charges.

This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information.

Incomplete/invalid laboratory report.Start: 08/01/2007Benefits are not available for incomplete service(s)/undelivered item(s).Start: 08/01/2007Missing elective consent form.Start: 08/01/2007Incomplete/invalid elective consent form.Start: 08/01/2007

Start: 08/01/2007Missing periodontal charting.Start: 08/01/2007Incomplete/invalid periodontal charting.Start: 08/01/2007Missing facility certification.Start: 08/01/2007Incomplete/invalid facility certification.Start: 08/01/2007This service is only covered when the donor's insurer(s) do not provide coverage for the service.Start: 08/01/2007This service is only covered when the recipient's insurer(s) do not provide coverage for the service.Start: 08/01/2007You are not an approved submitter for this transmission format.Start: 08/01/2007This payer does not cover deductibles assessed by a previous payer.Start: 08/01/2007

Start: 08/01/2007Not covered unless the prescription changes.Start: 08/01/2007 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)This service is allowed one time in a 6-month period.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 2 times in a 12-month period.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 2 times in a benefit year.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 4 times in a 12-month period.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 1 time in an 18-month period.Start: 08/01/2007 | Last Modified: 07/01/2016

Alert: Electronically enabled providers should submit claims electronically.

This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.

Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 1 time in a 3-year period.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)This service is allowed 1 time in a 5-year period.Start: 08/01/2007 | Last Modified: 07/01/2016Notes: (Modified 2/1/2009, Reactivated 7/1/2016)Misrouted claim. See the payer's claim submission instructions.Start: 08/01/2007Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.Start: 08/01/2007

Start: 08/01/2007Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.Start: 08/01/2007 | Last Modified: 05/08/2008Notes: (Modified 2/29/08, typo fixed 5/8/08)Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program.Start: 08/01/2007 | Last Modified: 05/08/2008Notes: (Typo fixed 5/8/08)Claim payment was the result of a payer's retroactive adjustment due to a non standard program.Start: 08/01/2007Patient does not reside in the geographic area required for this type of payment.Start: 08/01/2007Statutorily excluded service(s).Start: 08/01/2007No coverage when self-administered.Start: 08/01/2007Payment for eyeglasses or contact lenses can be made only after cataract surgery.Start: 08/01/2007Not covered when performed in this place of service.Start: 08/01/2007 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)Not covered when considered routine.Start: 08/01/2007 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)Procedure code is inconsistent with the units billed.Start: 11/05/2007Not covered with this procedure.Start: 11/05/2007 | Last Modified: 03/08/2011Notes: (Modified 3/8/11)

Start: 11/05/2007 | Last Modified: 07/01/2015Notes: (Modified 7/1/15)Resubmit this claim using only your National Provider Identifier (NPI).Start: 02/29/2008 | Last Modified: 03/14/2014

Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.

Alert: Adjustment based on a Recovery Audit.

Notes: (Modified 3/14/2014)Missing/Incomplete/Invalid Present on Admission indicator.Start: 07/01/2008Exceeds number/frequency approved /allowed within time period without support documentation.Start: 07/01/2008The injury claim has not been accepted and a mandatory medical reimbursement has been made.Start: 07/01/2008

Start: 07/01/2008This jurisdiction only accepts paper claims.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing anesthesia physical status report/indicators.Start: 07/01/2008Incomplete/invalid anesthesia physical status report/indicators.Start: 07/01/2008This missed/cancelled appointment is not covered.Start: 07/01/2008 | Last Modified: 07/15/2013Notes: (Modified 7/15/2013)Payment based on an alternate fee schedule.Start: 07/01/2008Missing/incomplete/invalid total time or begin/end time.Start: 07/01/2008

Start: 07/01/2008Missing document for actual cost or paid amount.Start: 07/01/2008Incomplete/invalid document for actual cost or paid amount.Start: 07/01/2008Payment is based on a generic equivalent as required documentation was not provided.Start: 07/01/2008This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Payment based on a comparable drug/service/supply.Start: 07/01/2008Covered only when performed by the primary treating physician or the designee.Start: 07/01/2008Missing Admission Summary Report.Start: 07/01/2008Incomplete/invalid Admission Summary Report.Start: 07/01/2008Missing Consultation Report.Start: 07/01/2008Incomplete/invalid Consultation Report.

Alert: If the injury claim is accepted, these charges will be reconsidered.

Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation.

Start: 07/01/2008Missing Physician Order.Start: 07/01/2008Incomplete/invalid Physician Order.Start: 07/01/2008Missing Diagnostic Report.Start: 07/01/2008Incomplete/invalid Diagnostic Report.Start: 07/01/2008Missing Discharge Summary.Start: 07/01/2008Incomplete/invalid Discharge Summary.Start: 07/01/2008Missing Nursing Notes.Start: 07/01/2008Incomplete/invalid Nursing Notes.Start: 07/01/2008Missing support data for claim.Start: 07/01/2008Incomplete/invalid support data for claim.Start: 07/01/2008Missing Physical Therapy Notes/Report.Start: 07/01/2008Incomplete/invalid Physical Therapy Notes/Report.Start: 07/01/2008Missing Tests and Analysis Report.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Incomplete/invalid Report of Tests and Analysis Report.Start: 07/01/2008

Start: 07/01/2008This payment will complete the mandatory medical reimbursement limit.Start: 07/01/2008Missing/incomplete/invalid HIPPS Rate Code.Start: 07/01/2008Payment for this service has been issued to another provider.Start: 07/01/2008Missing certification.Start: 07/01/2008Incomplete/invalid certification.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing completed referral form.Start: 07/01/2008

Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Incomplete/invalid completed referral form.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing Dental Models.Start: 07/01/2008Incomplete/invalid Dental Models.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).Start: 07/01/2008Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).Start: 07/01/2008Missing Models.Start: 07/01/2008Incomplete/invalid Models.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing Periodontal Charts.Start: 07/01/2008 | Stop: 05/01/2015 | Last Modified: 11/01/2014Notes: (Modified 11/1/2014)Incomplete/invalid Periodontal Charts.Start: 07/01/2008 | Stop: 05/01/2015 | Last Modified: 11/01/2014Notes: (Modified 3/14/2014, 11/1/2014)Missing Physical Therapy Certification.Start: 07/01/2008Incomplete/invalid Physical Therapy Certification.Start: 07/01/2008Missing Prosthetics or Orthotics Certification.Start: 07/01/2008Incomplete/invalid Prosthetics or Orthotics Certification.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing referral form.Start: 07/01/2008Incomplete/invalid referral form.Start: 07/01/2008 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing/Incomplete/Invalid Exclusionary Rider Condition.Start: 07/01/2008

Start: 07/01/2008Missing Doctor First Report of Injury.Start: 07/01/2008Incomplete/invalid Doctor First Report of Injury.Start: 07/01/2008

Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.

Missing Supplemental Medical Report.Start: 07/01/2008Incomplete/invalid Supplemental Medical Report.Start: 07/01/2008Missing Medical Permanent Impairment or Disability Report.Start: 07/01/2008Incomplete/invalid Medical Permanent Impairment or Disability Report.Start: 07/01/2008Missing Medical Legal Report.Start: 07/01/2008Incomplete/invalid Medical Legal Report.Start: 07/01/2008Missing Vocational Report.Start: 07/01/2008Incomplete/invalid Vocational Report.Start: 07/01/2008Missing Work Status Report.Start: 07/01/2008Incomplete/invalid Work Status Report.Start: 07/01/2008

Start: 11/01/2008

Start: 11/01/2008Plan distance requirements have not been met.Start: 11/01/2008

Start: 11/01/2008

Start: 11/01/2008

Start: 11/01/2008

Start: 11/01/2008

Start: 11/01/2008

Start: 11/01/2008

Alert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time.

Alert: This is an estimate of the member’s liability based on the information available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment.

Alert: This real time claim adjudication response represents the member responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions.

Alert: A current inquiry shows the member’s Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.

Alert: A current inquiry shows the member’s Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.

Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time.

Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication.

Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication.

Consult plan benefit documents/guidelines for information about restrictions for this service.Start: 11/01/2008 | Stop: 01/01/2011Notes: Consider using N130

Start: 11/01/2008 | Stop: 10/01/2009Records indicate a mismatch between the submitted NPI and EIN.Start: 03/01/2009Resubmit a new claim with the requested information.Start: 03/01/2009No separate payment for accessories when furnished for use with oxygen equipment.Start: 03/01/2009Invalid combination of HCPCS modifiers.Start: 07/01/2009

Start: 07/01/2009Mismatch between the submitted provider information and the provider information stored in our system.Start: 11/01/2009Duplicate of a claim processed, or to be processed, as a crossover claim.Start: 11/01/2009 | Last Modified: 03/01/2010

Start: 03/01/2010Based on policy this payment constitutes payment in full.Start: 03/01/2010These services are not covered when performed within the global period of another service.Start: 03/01/2010Not qualified for recovery based on employer size.Start: 03/01/2010We processed this claim as the primary payer prior to receiving the recovery demand.Start: 03/01/2010Patient is entitled to benefits for Institutional Services only.Start: 03/01/2010 | Last Modified: 07/01/2010Notes: (Modified 7/1/10)Patient is entitled to benefits for Professional Services only.Start: 03/01/2010 | Last Modified: 07/01/2010Notes: (Modified 7/1/10)Not Qualified for Recovery based on enrollment information.Start: 03/01/2010 | Last Modified: 07/01/2010Notes: (Modified 7/1/10)Not qualified for recovery based on direct payment of premium.Start: 03/01/2010Not qualified for recovery based on disability and working status.Start: 03/01/2010Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.Start: 07/01/2010

Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead)

Alert: Payment made from a Consumer Spending Account.

The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.

This is an individual policy, the employer does not participate in plan sponsorship.Start: 07/01/2010

Start: 07/01/2010

Start: 07/01/2010We have examined claims history and no records of the services have been found.Start: 07/01/2010

Start: 07/01/2010

Start: 07/01/2010Payment adjusted based on the interrupted stay policy.Start: 11/01/2010Mismatch between the submitted insurance type code and the information stored in our system.Start: 11/01/2010Missing income verification.Start: 03/08/2011Incomplete/invalid income verification.Start: 03/08/2011 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)


Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.

Start: 07/01/2011Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.Start: 07/01/2011A refund request (Frequency Type Code 8) was processed previously.Start: 03/06/2012

Start: 03/06/2012

Start: 03/06/2012

Start: 03/06/2012Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.Start: 03/06/2012Payment adjusted to reverse a previous withhold/bonus amount.Start: 03/06/2012Payment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status change.Start: 03/06/2012 | Stop: 11/01/2012

Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.

We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us.

A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.

Alert: We processed appeals/waiver requests on your behalf and that request has been denied.

Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected this will not be paid in the future.

Alert: Patient's calendar year deductible has been met.

Alert: Patient's calendar year out-of-pocket maximum has been met.

Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future.

Missing/Incomplete/Invalid Family Planning Indicator.Start: 07/01/2012 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Missing medication list.Start: 07/01/2012Incomplete/invalid medication list.Start: 07/01/2012

Start: 07/01/2012

Start: 07/01/2012

Start: 07/01/2012

The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.

Start: 11/01/2012

Start: 11/01/2012

Start: 11/01/2012

Start: 11/01/2012 | Last Modified: 11/01/2015Notes: Related to M39 (Modified 11/1/2015)Patient did not meet the inclusion criteria for the demonstration project or pilot program.Start: 11/01/2012


Start: 11/01/2012Not covered when considered preventative.Start: 03/01/2013

Start: 03/01/2013Not covered when performed for the reported diagnosis.Start: 03/01/2013Missing/incomplete/invalid credentialing data.Start: 03/01/2013 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)

Start: 03/01/2013

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.

The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.

The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.

Alert: Missing required provider/supplier issuance of advance patient notice of non-coverage. The patient is not liable for payment for this service.

Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed.

Alert: This procedure code requires functional reporting. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.

Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.

Alert: Payment will be issued quarterly by another payer/contractor.

This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.


Start: 03/01/2013

Start: 07/15/2013

Start: 07/15/2013Services not related to the specific incident/claim/accident/loss being reported.Start: 07/15/2013Personal Injury Protection (PIP) Coverage.Start: 07/15/2013Coverages do not apply to this loss.Start: 07/15/2013Medical Payments Coverage (MPC).Start: 07/15/2013Determination based on the provisions of the insurance policy.Start: 07/15/2013Investigation of coverage eligibility is pending.Start: 07/15/2013Benefits suspended pending the patient's cooperation.Start: 07/15/2013Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.Start: 07/15/2013Not covered based on the insured's noncompliance with policy or statutory conditions.Start: 07/15/2013Benefits are no longer available based on a final injury settlement.Start: 07/15/2013The injured party does not qualify for benefits.Start: 07/15/2013Policy benefits have been exhausted.Start: 07/15/2013The patient has instructed that medical claims/bills are not to be paid.Start: 07/15/2013

Start: 07/15/2013

Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.

Start: 07/15/2013Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).Start: 07/15/2013Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.Start: 07/15/2013

Alert: You have been overpaid and must refund the overpayment. The refund will be requested separately by another payer/contractor.

Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.

Not covered based on failure to attend a scheduled Independent Medical Exam (IME).Start: 07/15/2013Records reflect the injured party did not complete an Application for Benefits for this loss.Start: 07/15/2013Records reflect the injured party did not complete an Assignment of Benefits for this loss.Start: 07/15/2013Records reflect the injured party did not complete a Medical Authorization for this loss.Start: 07/15/2013

Start: 07/15/2013 | Last Modified: 11/01/2013Health care policy coverage is primary.Start: 07/15/2013

Start: 07/15/2013Adjusted based on the applicable fee schedule for the region in which the service was rendered.Start: 07/15/2013

Start: 07/15/2013Adjusted based on the Redbook maximum allowance.Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013Service provided for non-compensable condition(s).Start: 07/15/2013

Start: 07/15/201380% of the provider's billed amount is being recommended for payment according to Act 6.Start: 07/15/2013 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)

Adjusted based on a medical/dental provider's apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.

Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered.

In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.

This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.

In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.

This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.

The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.

Alert: Payment based on an appropriate level of care.

Start: 07/15/2013Claim in litigation. Contact insurer for more information.Start: 07/15/2013Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013

Start: 07/15/2013This enrollee is in the second or third month of the advance premium tax credit grace period.Start: 07/15/2013

Start: 07/15/2013Coverage terminated for non-payment of premium.Start: 07/15/2013

Start: 07/15/2013Charges for Jurisdiction required forms, reports, or chart notes are not payable.Start: 07/15/2013Not covered based on the date of injury/accident.Start: 07/15/2013Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.Start: 07/15/2013The associated Workers' Compensation claim has been withdrawn.Start: 07/15/2013Missing/Incomplete/Invalid Workers' Compensation Claim Number.Start: 07/15/2013New or established patient E/M codes are not payable with chiropractic care codes.Start: 07/15/2013Service not payable per managed care contract.Start: 07/15/2013 | Stop: 07/01/2014Notes: Consider Use CARC 256Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.Start: 07/15/2013Reviews/documentation/notes/summaries/reports/charts not requested.

Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.

Alert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information).

Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.

Alert: This enrollee is in the first month of the advance premium tax credit grace period.

Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.

Alert: This procedure code is for quality reporting/informational purposes only.

Start: 07/15/2013Referral not authorized by attending physician.Start: 07/15/2013Medical Fee Schedule does not list this code. An allowance was made for a comparable service.Start: 07/15/2013

According to the Official Medical Fee Schedule this service has a relative value of zero and therefore no payment is due.

Start: 07/15/2013 | Stop: 07/01/2014Notes: Consider using W8Additional anesthesia time units are not allowed.Start: 07/15/2013The allowance is calculated based on anesthesia time units.Start: 07/15/2013The Allowance is calculated based on the anesthesia base units plus time.Start: 07/15/2013Adjusted because this is reimbursable only once per injury.Start: 07/15/2013Consultations are not allowed once treatment has been rendered by the same provider.Start: 07/15/2013Reimbursement has been made according to the home health fee schedule.Start: 07/15/2013Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.Start: 07/15/2013Exceeds number/frequency approved/allowed within time period.Start: 07/15/2013Reimbursement has been based on the number of body areas rated.Start: 07/15/2013Adjusted when billed as individual tests instead of as a panel.Start: 07/15/2013The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.Start: 07/15/2013Reimbursement has been made according to the bilateral procedure rule.Start: 07/15/2013Mark-up allowance.Start: 07/15/2013 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Reimbursement has been adjusted based on the guidelines for an assistant.Start: 07/15/2013Adjusted based on diagnosis-related group (DRG).Start: 07/15/2013Adjusted based on Stop Loss.Start: 07/15/2013Payment based on invoice.Start: 07/15/2013This policy was not in effect for this date of loss. No coverage is available.Start: 07/15/2013

No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.Start: 07/15/2013The date of service is before the date of loss.Start: 07/15/2013The date of injury does not match the reported date of loss.Start: 07/15/2013Adjusted based on achievement of maximum medical improvement (MMI).Start: 07/15/2013Payment based on provider's geographic region.Start: 07/15/2013An interest payment is being made because benefits are being paid outside the statutory requirement.Start: 07/15/2013This should be billed with the appropriate code for these services.Start: 07/15/2013The billed service(s) are not considered medical expenses.Start: 07/15/2013This item is exempt from sales tax.Start: 07/15/2013Sales tax has been included in the reimbursement.Start: 07/15/2013Documentation does not support that the services rendered were medically necessary.Start: 07/15/2013

Start: 07/15/2013Adjusted based on an agreed amount.Start: 07/15/2013Adjusted based on a legal settlement.Start: 07/15/2013Services by an unlicensed provider are not reimbursable.Start: 07/15/2013Only one evaluation and management code at this service level is covered during the course of care.Start: 07/15/2013Missing prescription.Start: 07/15/2013 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Incomplete/invalid prescription.Start: 07/15/2013 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Adjusted based on the Medicare fee schedule.Start: 07/15/2013

Start: 07/15/2013Payment based on a jurisdiction cost-charge ratio.Start: 07/15/2013

Alert: Consideration of payment will be made upon receipt of a final bill.

This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

Alert: Amount applied to Health Insurance Offset.

Start: 07/15/2013

Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.

Start: 07/15/2013Not covered unless a pre-requisite procedure/service has been provided.Start: 07/15/2013Additional information is required from the injured party.Start: 07/15/2013Service does not qualify for payment under the Outpatient Facility Fee Schedule.Start: 07/15/2013

Start: 11/01/2013Missing post-operative images/visual field results.Start: 11/01/2013Incomplete/Invalid post-operative images/visual field results.Start: 11/01/2013Missing/Incomplete/Invalid date of previous dental extractions.Start: 11/01/2013Missing/Incomplete/Invalid full arch series.Start: 11/01/2013Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.Start: 11/01/2013Missing/Incomplete/Invalid prior treatment documentation.Start: 11/01/2013Payment denied as this is a specialty claim submitted as a general claim.Start: 11/01/2013Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.Start: 11/01/2013Missing/incomplete/Invalid questionnaire needed to complete payment determination.Start: 11/01/2013

Start: 11/01/2013 | Last Modified: 03/14/2014Notes: To be used with claim/service reversal. (Modified 3/14/2014)





Alert: Films/Images will not be returned.

Alert: This reversal is due to a retroactive disenrollment.

Alert: This reversal is due to a medical or utilization review decision.

Alert: This reversal is due to a retroactive rate change.

Alert: This reversal is due to a provider submitted appeal.

Alert: This reversal is due to a patient submitted appeal.

Alert: This reversal is due to an incorrect rate on the initial adjudication.



Start: 11/01/2013

Start: 11/01/2013



Start: 11/01/2013 | Last Modified: 11/01/2015Notes: To be used with claim/service reversal. (Modified 3/14/2014, 11/1/2015)Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.Start: 03/01/2014Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.Start: 03/01/2014Payment adjusted based on the Value-based Payment Modifier.Start: 03/01/2014

Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.

Start: 03/01/2014This service is incompatible with previously adjudicated claims or claims in process.Start: 03/01/2014

Start: 03/01/2014 | Last Modified: 03/14/2014Notes: (Modified 3/14/2014)Incomplete/invalid documentation.Start: 03/01/2014Missing documentation.Start: 03/01/2014Incomplete/invalid orders.Start: 03/01/2014Missing orders.Start: 03/01/2014Incomplete/invalid notes.Start: 03/01/2014Missing notes.Start: 03/01/2014Incomplete/invalid summary.

Alert: This reversal is due to a cancellation of the claim by the provider.

Alert: This reversal is due to a resubmission/change to the claim by the provider.

Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication.

Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.

Alert: This reversal is due to a payer's retroactive contract incentive program adjustment.

Alert: This reversal is due to non-payment of the health insurance premiums (Health Insurance Exchange or other) by the end of the premium payment grace period, resulting in loss of coverage.

Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.

Start: 03/01/2014Missing summary.Start: 03/01/2014Incomplete/invalid report.Start: 03/01/2014Missing report.Start: 03/01/2014Incomplete/invalid chart.Start: 03/01/2014Missing chart.Start: 03/01/2014Incomplete/Invalid documentation of face-to-face examination.Start: 03/01/2014Missing documentation of face-to-face examination.Start: 03/01/2014Penalty applied based on plan requirements not being met.Start: 03/01/2014

Start: 03/01/2014This service is only covered when performed as part of a clinical trial.Start: 03/01/2014Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item.Start: 03/01/2014Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.Start: 03/01/2014Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.Start: 03/01/2014A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.Start: 03/01/2014A conditional payment is not allowed.Start: 03/01/2014A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.Start: 03/01/2014

A workers' compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Start: 03/01/2014Missing patient medical/dental record for this service.Start: 11/01/2014Incomplete/invalid patient medical/dental record for this service.Start: 11/01/2014Incomplete/Invalid mental health assessment.Start: 11/01/2014Services performed at an unlicensed facility are not reimbursable.Start: 11/01/2014Regulatory surcharges are paid directly to the state.

Alert: The patient overpaid you. You may need to issue the patient a refund for the difference between the patient’s payment and the amount shown as patient responsibility on this notice.

Start: 11/01/2014

Start: 11/01/2014

Start: 03/01/2015 | Stop: 01/01/2016Incomplete/invalid Sleep Study Report.Start: 03/01/2015Missing Sleep Study Report.Start: 03/01/2015Incomplete/invalid Vein Study Report.Start: 03/01/2015Missing Vein Study Report.Start: 03/01/2015

Start: 03/01/2015This is a site neutral payment.Start: 03/01/2015

Start: 03/01/2015 | Stop: 11/01/2016 | Last Modified: 11/01/2015Notes: (Modified 11/1/2015)Adjusted because the services may be related to an employment accident.Start: 03/01/2015Adjusted because the services may be related to an auto accident.Start: 03/01/2015Missing Ambulance Report.Start: 03/01/2015Incomplete/invalid Ambulance Report.Start: 03/01/2015This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.Start: 03/01/2015Adjusted because the related hospital charges have not been received.Start: 03/01/2015Missing Blood Gas Report.Start: 03/01/2015Incomplete/invalid Blood Gas Report.Start: 03/01/2015Adjusted because the drug is covered under a Medicare Part D plan.Start: 03/01/2015Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).Start: 03/01/2015Missing/incomplete/invalid Attachment Control Number.Start: 07/01/2015

The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.

Adjustment without review of medical/dental record because the requested records were not received or were not received timely.

The member's Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service.

Alert: This claim was processed based on one or more ICD-9 codes. The transition to ICD-10 is required by October 1, 2015, for health care providers, health plans, and clearinghouses. More information can be found at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.Start: 07/01/2015Missing/incomplete/invalid ICD Indicator.Start: 07/01/2015 | Last Modified: 03/01/2016Notes: (Modified 3/1/2016)Missing/incomplete/invalid point of drop-off address.Start: 07/01/2015Adjusted based on the Federal Indian Fees schedule (MLR).Start: 07/01/2015Adjusted based on the prior authorization decision.Start: 07/01/2015Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.Start: 07/01/2015This facility is not authorized to receive payment for the service(s).Start: 11/01/2015This provider is not authorized to receive payment for the service(s).Start: 11/01/2015This facility is not certified for Tomosynthesis (3-D) mammography.Start: 11/01/2015The demonstration code is not appropriate for this claim; resubmit without a demonstration code.Start: 11/01/2015Missing/incomplete/invalid Hematocrit (HCT) value.Start: 03/01/2016This payer does not cover co-insurance assessed by a previous payer.Start: 03/01/2016This payer does not cover co-payment assessed by a previous payer.Start: 03/01/2016

Start: 03/01/2016Incomplete/invalid initial evaluation report.Start: 03/01/2016A lateral diagnosis is required.Start: 03/01/2016

Start: 03/01/2016

Start: 07/01/2016

Start: 07/01/2016Drug supplied not obtained from specialty vendor.Start: 07/01/2016

Start: 07/01/2016

The Medicaid state requires provider to be enrolled in the member’s Medicaid state program prior to any claim benefits being processed.

The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the information received.

Alert: Under Federal law you cannot charge more than the limiting charge amount.

Alert: Rebill urgent/emergent and ancillary services separately.

Alert: Refer to your Third Party Processor Agreement for specific information on fees associated with this payment type.

Payment adjusted based on x-ray radiograph on film.Start: 11/01/2016This service is not a covered Telehealth service.Start: 11/01/2016Missing Medicare Assignment of Benefits Indicator.Start: 11/01/2016Missing Primary Care Physician Information.Start: 11/01/2016

Start: 11/01/2016Missing/incomplete/invalid end therapy date.Start: 11/01/2016

Start: 11/01/2016

Start: 11/01/2016

Start: 11/01/2016Missing comprehensive procedure code.Start: 11/01/2016Missing current radiology film/images.Start: 11/01/2016Benefit limitation for the orthodontic active and/or retention phase of treatment.Start: 11/01/2016

Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is received.

Alert: No deductible may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible.

Alert: No coinsurance may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance.

Alert: No co-payment may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected co-payment.

Denied Claims Report- Definitions

Any instructions or definitions not followed will result in rejected reports.

DETAILED DENIED CLAIMS REPORT

Note: Professional and Outpatient claims are counted at the line level (includes claims types: 10 and 11).

DENTAL SUMMARY

LDH requires that health plans submit a monthly report showing all denied claims. Spreadsheet should be populated with records where date of processing (date denied) falls within the reporting period.

The report shall be submitted to the Reporting 2.0 site in an Excel Spreadsheet by the 15 th of the month following the end of the reporting period. The Excel Spreadsheet shall include one tab each for Dental Summary, Dental Detail, CARC Dictionary, RARC Dictionary, and Definitions Page.

At a minimum, the Detailed Denied Claims reports shall include:

· Report heading, which includes:v Dental Plan ID:v Dental Plan Name:v Dental Plan Contact:v Contact Email:v Report Period Start Date:v Report Period End Date:v Submission Date of Report:

· Medicaid ID (13-digit Medicaid ID number);· Billing Provider NPI - (National Provider Identifier);· Servicing Provider NPI (National Provider Identifier);· Plan Internal Control Number (ICN) for the claim;· Billing Provider Type;· Billing Provider Taxonomy code (if applicable)· Servicing Provider Type;· Servicing Provider Taxonomy code (if applicable)· Claim type (LDH 2 digit code);· ER = 0 Non-ER = 1: ER/Non-ER = Emergency service or Non-Emergency Service adjudicated during the reporting period; reported as 0 or 1 only. Emergency services are defined as claim type 03 with revenue codes 450, 459 or 981 (outpatient hospital) and claim type 04 with procedure codes 99281 through 99285 (professional).

· Date of service;· Provider billed amount (include decimal point followed by 2 digits);· Date Received- Date of receipt by the Health Plan;· Date Denied;· Primary diagnosis code (if applicable)· CDT code(s) (if applicable)· Revenue code(s) (if applicable): For Inpatient records, the Revenue Code field can be blank or can be the first Service-Line’s Revenue Code value, but do not send more than 1 Revenue Code per Inpatient record and do not list the same Inpatient record on more than 1 row of the report.

· PA approved (Y/N): If prior authorization was processed and approved for a particular service and claim was subsequenetly denied, indicate Y for yes. Otherwise, indicate N for no.

· CARC code 1 : Claims Adjustment Reason Code as per CARC dictionary tab. Shall be at least one per denied claim/encounter· CARC code 2 (if applicable)· CARC code 3 (if applicable)· CARC code 4 (if applicable)· CARC code 5 (if applicable)· RARC code 1 : Remittance Advice Remark Code as per RARC dictionary tab (if applicable according to CARC directive)· RARC code 2 (if applicable according to CARC directive)· RARC code 3 (if applicable according to CARC directive)

Please note that some fields are to be populated only if applicable. If not applicable, leave field blank and do not enter N/A, NULL, or other entry. All other fields are required and must be populated by the health plans and/or the health plan subcontractors.

Reports submitted by the dental plan subcontractors must have all required fields populated. It is the health plans responsibility to ensure that these reports contain all required data as outlined here.

The Dental Denied Claims Summary should contain a breakdown of all CARCs (showing the description from the CARC dictionary), with totals for each individual code. Note that the total count of CARCs will be higher than total denied claims from the Dental Detail tab of the report because there may be multiple CARCs associated with a single denied claim.

[xls] · web viewthis is a non-covered service because it is a routine/preventive exam or a...

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